Provider Demographics
NPI:1720089824
Name:VUCICEVIC, SLOBODAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:SLOBODAN
Middle Name:D
Last Name:VUCICEVIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3263
Mailing Address - Country:US
Mailing Address - Phone:708-749-0117
Mailing Address - Fax:708-749-8593
Practice Address - Street 1:3501 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3263
Practice Address - Country:US
Practice Address - Phone:708-749-0117
Practice Address - Fax:708-749-8593
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055452207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2221384OtherBLUE CROSS BLUE SHIELD
IL036055452Medicaid
IL672600OtherMEDICARE ID TYPE UNSPECIF
IL363203419OtherTAX IDENTIFICATION
IL363203419OtherTAX IDENTIFICATION
IL672600OtherMEDICARE ID TYPE UNSPECIF
IL2221384OtherBLUE CROSS BLUE SHIELD